Advocacy Form

Home Advocacy Form

If you have accessibility issues regarding this form, please email us at advocacysupport@dacssa.org.au

URL
This field is for validation purposes and should be left unchanged.
Who are you requesting Advocacy for?*
What is your relationship to the person requiring DACSSA assistance?*
Consent

Before progressing, DACSSA will need to understand that you have consent to act on behalf of this person e.g. Parent, Legal Guardian, or through written authority. Please refer to our Terms and Conditions.

In line with Australian Privacy legislation, DACSSA must consider privacy of people with disability to be of paramount importance. This is aligned with our person-centred philosophy that promotes participation and inclusion of people living with disability to make choices about the services they use. 

Consent means that a person has agreed to you acting on their behalf to contact DACSSA. Consent can happen verbally including via communication devices, or in writing.

DACSSA must be satisfied that you have consent to act on behalf of the person living with disability and we ask that you be responsible for championing the right to privacy for people living with disability. 
Does the person requiring DACSSA assistance have the capacity to give their consent?*
- Yes
- No
DACSSA must be satisfied that you have consent to act on behalf of a person with disability. Please call DACSSA on (08) 7122 6030 to talk about consent and explore your options.
Privacy Policy*
- I confirm I have read DACSSA's privacy policy and declare I have consent, ample in protecting the rights of the person I act for?
If you have written consent to contact DACSSA, please upload your consent document here.
Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 25 MB.
Details of the person making referral
Full Name*
Organisation
Phone
Email
Details of the person requiring DACSSA assistance
Full Name*
Date of Birth
Gender
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What do you identify as being your disability?
Additional Disability (if applicable)
Communication assistance required
- Yes
- No
If yes, please provide details (eg Auslan, interpreter, etc)
Do you identify as being Aboriginal or Torres Straight Islander
- Yes
- No
Do you identify as being from a culturally or linguistically diverse background?
- Yes
- No
If yes, which Country?
Main issue you require assistance with
Details
250 word limit
Relevant Dates, Appointments or Deadlines
250 word limit
How did you find out about DACSSA?
- Previous client
- Word of Mouth
- Brochure/literature
- Referral
- Online search e.g. Google
Privacy Policy*
- I confirm I have read and agree to DACSSA's privacy policy

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Consent

Details of the person making referral

Details of the person requiring DACSSA assistance